Assessing Cannabis Use: The Case Of Gabby
Consider how you might assess Gabby’s cannabis use. Consider any ethical, legal, or cultural issues that may arise in assessing her cannabis use. Explain how you might assess Gabby’s cannabis use. Explain why this assessment might be effective. Describe one potential ethical or legal issue related to Gabby’s case and explain how you might address it.
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Journal of Social Work Practice in the Addictions
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A Review of Marijuana Assessment Dilemmas: Time for Marijuana Specific Screening Methods?
Dale Alexander PhD
To cite this article: Dale Alexander PhD (2003) A Review of Marijuana Assessment Dilemmas: Time for Marijuana Specific Screening Methods?, Journal of Social Work Practice in the Addictions, 3:4, 5-28, DOI: 10.1300/J160v03n04_02
To link to this article: https://doi.org/10.1300/J160v03n04_02
Published online: 17 Oct 2008.
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A Review of Marijuana Assessment Dilemmas:
Time for Marijuana Specific Screening Methods?
ABSTRACT. This article explores how multiple cultural and clinical factors regarding marijuana complicate accurate clinical recognition, assessment and diagnosis of cannabis use disorders. These factors in- clude: Widespread use of marijuana; culturally confusing messages about marijuana’s acceptability or harmfulness; social policy debates over legalization and decriminalization; scientific debates about mari- juana’s risks or medical benefits; DSM-IV-TR assessment criterion shortcomings; and the inadequacy of current screening methods related
Dale Alexander, PhD, is Associate Professor at the University of Houston Graduate School of Social Work, Houston, TX 77204-4013 (E-mail: firstname.lastname@example.org).
The author thanks Dr. Paul Raffoul, Dr. Scott Basinger, and Les Shireman for re- view and comments, and Lindsey Alexander for editing assistance.
Research support for this review was provided in part by a University of Houston Faculty Grant and HRSA/AMERSA/SAMHSA PROJECT MAINSTREAM fellow- ship grant.
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2003 by The Haworth Press, Inc. All rights reserved. 10.1300/J160v03n04_02 5
to marijuana. These issues are described along with a potential rem- edy–the development of marijuana specific screening methods.[Article copies available for a fee from The Haworth Document Delivery Service: 1-800- HAWORTH. E-mail address: <email@example.com> Website: <http:// www. HaworthPress.com> © 2003 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Marijuana, assessment, Marijuana Screening Inventory, cannabis abuse, substance abuse assessment, drug abuse
Marijuana assessment is a complicated and challenging task, made more difficult because of cultural and clinical controversies swirling around the use of marijuana. Most clinicians rely upon the traditional methods of the clinical interview and the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-IV-TR) criteria as the gold standards for assessment of different substance disorders, including marijuana (American Psychiatric Association [APA], 2000; Clark, 1999). However, many social workers are challenged in assessing for marijuana problems due to limited training in the use of DSM-IV (Dziegielewski, Johnson, & Webb, 2002), and more importantly, in their knowledge of assessing for substance use disorders (SUD) (Alaszewski & Harrison, 1992; Amodeo & Fassler, 2000; Hall, Amodeo, Shaffer, & Bilt, 2000). Straussner and Senreich (2002, p. 319) report “most social workers receive limited or no training in effective as- sessment” of substance use disorders, adding “the estimated 400,000 so- cial workers in the U.S. are thus dealing with the numerous consequences of substance abuse without fully understanding the nature of addiction or having the skills needed to directly address SUD (substance use disor- ders).” Adding to these training deficits are other factors flowing from the cultural and clinical contexts that pile extra dilemmas onto the marijuana assessment process. The purpose of this review is to highlight the multi- ple cultural and clinical factors complicating marijuana assessment, and point toward a potential remedy complimenting traditional assess- ment–the development of marijuana specific screening methods.
THE CONTEXT AROUND MARIJUANA ASSESSMENT
Traditional marijuana assessment methods are impacted by factors emanating from the cultural and clinical contexts. The cultural factors
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contributing to marijuana assessment dilemmas include: Cultural disso- nance between behavior and risk reflected by marijuana’s widespread use; culturally confusing messages about marijuana’s acceptability or harmfulness; social policy debates over legalization and decriminaliza- tion; and scientific debates about marijuana’s risks or “medical” bene- fits. Clinical factors also challenge social workers, such as: Marijuana is not the presenting problem in most settings; client reluctance to disclose marijuana use; clinician uncertainty about when or how to ask about marijuana use, or what constitutes a marijuana problem pattern; the lack of consensus regarding marijuana frequency measures; difficulties in applying DSM-IV-TR dependence and abuse diagnostic criteria to mari- juana; and, inadequacies of existing laboratory and drug screening in- ventories in assessing for marijuana problems.
Marijuana Prevalence Reflects Cultural Dissonance
Marijuana, despite its illegality, continues to be the most widely used illicit drug in the U.S., preceded in prevalence only by alcohol and to- bacco (Johnston, O’Malley, & Bachman, 2001; Substance Abuse and Mental Health Services Administration [SAMHSA], 2002a). Two na- tional surveys provide annually updated information about illicit drug use. The Monitoring the Future Study (2001) suggests lifetime mari- juana prevalence increased during the last 25 years from 53% to 78% for those between ages 19 to 40 (Johnston et al., 2001, p. 89). The Na- tional Household Survey on Drug Abuse estimates that 50% of 18- to 25-year-olds and 37% of those 26 years or older have used marijuana (SAMHSA, 2002b). Marijuana use increased significantly from 2000 to 2001, shifting from 4.8% to 5.4% of the population reporting past month use (SAMHSA, 2002a). Of the 15.9 million Americans using il- licit drugs in a past month (7.1% of the population), 56% consumed only marijuana, 20% used marijuana plus another drug, and only 24% used illicit drugs other than marijuana (SAMHSA, 2002a). These statis- tics highlight that marijuana is used by a majority of those involved with “illicit drugs.” Marijuana use varies by age, gender, ethnicity, neighbor- hood, and frequency of use. Of the 9.3% of the population reporting past year marijuana use, 35.4% used marijuana 100 or more days and 11.9% used it 300 or more days. Among past month marijuana users, 32% used it for 20 days or more, and another 22.8% used it six to 19 days (SAMHSA, 2002c). The trend toward more frequent marijuana use continues (SAMHSA, 2002c).
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Since in most states there are criminal penalties for marijuana pos- session, with arrests for marijuana exceeding six million since 1992, it remains surprising that so many adults risk using this substance (Fed- eral Bureau of Investigation [FBI], 2002). Marijuana’s prevalence sug- gests that its use is due not just to marijuana’s availability, but also to the decline in marijuana’s “perceived risks” (SAMHSA, 2002a). More people may use marijuana as they become less concerned about its risks as a “gateway” to harder drug use. Some studies find marijuana to be a less likely “gateway” to illicit drug use than tobacco and alcohol (Joy, Watson, & Benson, 1999; Morgan & Zimmer, 2002). A study by Morral, McCaffrey, and Paddock (2002) dismisses the “gateway the- ory,” indicating that their findings “raise serious questions about the legitimacy of basing national drug policy decisions on the false as- sumption that marijuana is a gateway drug” (p. 1499). Recent evidence, however, supports that marijuana use between ages 14 and 17 is an in- creased risk factor for higher rates of adult drug use (Gfroerer, Wu, & Penne, 2002; Lynskey et al., 2003). Moreover, according to the Na- tional Institute of Drug Abuse (NIDA) Acting Director Hanson, in his introduction to NIDA’s research summary on Marijuana Abuse (2002), “the use of marijuana can produce adverse physical, mental, emotional and behavioral changes . . . can be addictive . . . can harm the lungs . . . impair and weaken the immune system . . . impair short-term memory, verbal skills, judgment and distort perception . . . increase the likelihood of developing cancer . . . and have profound negative effects upon [teen- age] development.”
Despite such findings, more people may use marijuana believing that: (1) Marijuana is a “soft” recreational drug, unlike the “hard, dan- gerous” drugs such as heroin or cocaine. (2) Since marijuana use is so widespread, it cannot be harmful. (3) Marijuana is “less dangerous” or, at least, no more harmful than alcohol (Zogy Poll, 2002). (4) Unlike chronic excessive drinkers who develop major physical complications such as cirrhosis, and are labeled alcoholics, chronic excessive mari- juana users are not perceived as risking physical complications, nor are they labeled “marijuanaolics.” (5) Overdose deaths resulting from other illicit drugs, such as heroin, cocaine, opioids, and ecstasy, have never been attributed to marijuana.
Culturally Confusing Messages Add Assessment Dilemmas
While governmental media campaigns and TV public service mes- sages indicate marijuana use contributes to accidents and narco-ter-
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rorism, pop culture reverberates with messages that marijuana use, even frequent use, is acceptable and not harmful (Office of National Drug Control Policy Media Campaign, 2002). As an example, the No- vember 2002 cover of Time magazine conveys this cultural confusion by picturing a pack of marijuana cigarettes and asking, “Is America going to pot?” While less mainstream than Time magazine, High Times and Cannabis Culture are widely circulated pro-marijuana magazines publishing articles that send messages normalizing marijuana use with topics ranging from how to grow marijuana to “counseling” how to pass drug tests. Singers, actors, athletes, comedians, educators, lawyers, and politicians indicate they use marijuana and do not find it harmful (Newsmakers, 2002, 2003; Reuters, 2003; Richardson, 2002). A New York Times (2002) advertisement applauds politicians’ “candor . . . for admitting . . . they’ve smoked pot,” suggesting even high functioning people in high places “get high.” Conservative, centrist and liberal poli- ticians from former Majority Leader Gingrich to former President Carter to Congressman Frank, endorsed repeal of criminal penalties for small amounts of marijuana (National Organization for Reform of Mar- ijuana Laws [NORML], 2002a; Schlosser, 2003; Stein, 2002). TV and newspaper journalists suggest the “new prohibition” on recreational marijuana use deserves less priority than other domestic issues (Keller, 2002; Stossel, 2002). National polls regarding marijuana use show that the majority of Americans oppose current marijuana policies, favor de- criminalization and support legalization of medical marijuana (Stein, 2002; Zogy, 2001).
Even farmers and agribusiness send confusing messages about mari- juana’s acceptability. While some warn that the industrial hemp move- ment is a disguise for legalizing marijuana use, others seriously promote hemp as a replacement for tobacco crop subsidies in southern states (Edi- torial, 1996; McDougal, 2002). “Farm production” of recreationally used marijuana is a “top ten cash crop” in many states, and supports a vast underground economy with 35% of marijuana consumed in the U.S. “grown in America” (Kane, 2002; NORML, 2002b; Schlosser, 2003). Forbes, the business magazine, even discusses the future profit margins and Starbucks franchise potential of Holland’s “cannabis cafés” if this business model is ever imported to the U.S. (Morais, 1996).
The Baby Boomer generation is accused of sending messages that marijuana use is acceptable, because those entering adulthood in the 60s and 70s were more likely to have used marijuana than previous genera- tions. Newspaper headlines declare: “Survey finds babyboomer parents expect kids to try marijuana,” and see “experimentation as normal” (As-
Dale Alexander 9
sociated Press, 1996). The ramifications are reflected in surveys that in- dicate when parents “strongly disapproved” of marijuana, only 5% of adolescents used marijuana, while 27% of adolescents used marijuana when parents did not “strongly disapprove” (NHSDA report, 2002). The White House Drug Policy Director attributed the 2001 increases in marijuana use to “a fundamental misunderstanding propagated by the baby boomer generation that marijuana is safe and should be legal,” em- phasizing that “the wrong message” is being communicated (Chatterjee, 2002, p. 17A).
The accumulation of these culturally mixed messages complicates marijuana assessment with a perception of normality that blurs the line between “experimental,” “normal,” “regular,” or “problematic” mari- juana use patterns. Is the use of marijuana during a designated time frame, such as within the last year or past six months, sufficient by itself to meet the criteria of abuse or “at risk” use? (Fleming, 2002). These culturally as well as professionally mixed messages are also reflected in several ongoing social policy debates about marijuana.
Marijuana Policy Debates Add Assessment Dilemmas
Marijuana use is in the middle of three overlapping social policy de- bates: Decriminalization, legalization, and medical marijuana use. These debates are healthy, but amplify cultural ambivalence around marijuana use and inject controversy and conflicting messages into the assessment process.
In 1986, 75% of Americans saw drugs, including marijuana, as a ma- jor national problem and 26 new mandatory sentences for drug offenses were enacted (Baum, 1997). But the political debate to decriminalize and legalize “small amounts” of marijuana possession is longstanding. In 1977, President Carter said: “Penalties against drug use should not be more damaging to an individual than the use of the drug itself. Nowhere is this more clear than in the laws against the possession of marijuana in private for personal use” (NORML, 2002a). Still, half of all U.S. drug arrests are for marijuana (FBI, 2002); of 723,627 arrested in 2001 for marijuana violations 641,108 or 88.6% were charged with possession only, not sales or cultivation (FBI, 2002). Citizens question if marijuana penalties are deterring use or are more damaging than the actual use.
Criminal sanctions against marijuana have been compared in deter- rence value to the failed “prohibition” policy toward alcohol (Baum, 1997; NORML, 2002a; Stossel, 2002). Reports estimate 25% to 40% of the $31 billion annual costs of the “war on drugs” are directed to-
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ward law enforcement aimed only at marijuana use and possession (NORML, 2002a; Schlosser, 2003). Some suggest this expenditure on law enforcement and the criminalization of marijuana use is either a waste or a misdirection of funds better invested in treatment (Grinspoon & Bakalar, 1994; Stossel, 2002). The risks of ecstasy, cocaine and heroin abuse are seen as meriting more attention and concern than marijuana use. This side of the marijuana policy debate is gaining visibility from TV, movies, such as Traffic, influential people like financier George Soros, as well as judges and police chiefs (Soros, 2002; Stein, 2002; Stossel, 2002). Others argue that “legalizing marijuana would be irre- sponsible,” and the “government war on marijuana should be main- tained” (Brown, 2002; Souder, 1999). Those in charge of drug policy argue even more forcefully and persuasively that “marijuana is not some harmless chemical toy but a clear and present danger to the health and well-being of all its users” (Thompson, 2002). National Drug Con- trol Strategy continues to focus on “reducing the availability of danger- ous substances” by “making drugs scarce and expensive” and “eroding the economic base of the drug trade” to make it “more dangerous and less profitable” (Bush, 2003; Walters, 2003, press release).
Decriminalization of personal marijuana use in many European coun- tries persistently raises benchmark questions regarding our own laws (Ford, 2002; Hoge, 2002). Closer to our borders, Canada is considering decriminalizing marijuana possession and legalizing limited marijuana cultivation, based upon Canadian House of Commons and Senate re- ports concluding: “the consequences of conviction for possession of a small amount of cannabis for personal use are disproportionate to the potential harm” and “an utterly irrational restraint that has nothing to do with scientific or public health considerations” (Chatterjee, 2002; NORML, 2003). Nevada’s attempt to be the first state, after legalizing medical marijuana, to legalize possession of three ounces of marijuana, with direct sales regulated to derive tax revenues similar to tobacco and alcohol, recently failed with 39% of the vote (Cobb, 2002; Janofsky, 2002).
The high costs of law enforcement, court cases, and incarceration for marijuana users are being questioned. Arizona and California voters passed laws requiring treatment instead of prison for nonviolent drug offenses in 1996 and 2000, respectively; however, a similar ballot ini- tiative in Ohio failed in 2002 (Iguchi & Merritt, 2003; McCarthy, 2002). Interestingly, comparable “treatment only” costs for clients diagnosed with marijuana abuse are undetermined (Iguchi & Merritt, 2003). How- ever, as state budget crises grow nationwide, expenditures for incarcera-
Dale Alexander 11
tion versus treatment of marijuana offenses may undergo closer scrutiny and ballot initiatives similar to California’s court diversion programs may expand (Newhouse, 2002).
The debate to decriminalize and legalize marijuana has recently been amplified by the medical marijuana movement and state propositions to legalize prescription marijuana. The medical marijuana debate further clouds the risks or benefits of marijuana use (Bacalar, 1999; Gerdes, 2002; Grinspoon & Stroup, 1999; Ungerleider, 1999). To date, nine states have legalized medical marijuana and numerous health organiza- tions have endorsed its use, including the American Medical Associa- tion, American Academy of Family Physicians, American Society of Addiction Medicine, managed-care companies, numerous medical journals, and multiple state medical and nursing associations (NORML, 2002c). The medical marijuana debate also spills into the scientific de- bate about the harms and benefits of marijuana, which is addressed later.
These three policy debates are altering or eroding public perceptions that marijuana is an illicit and illegal drug justifiably deserving of the stigma of incarceration or other legal sanctions. The cultural gap be- tween public policy and public opinion has widened over time. A recent poll (Stein, 2002) reports 72% favor not jailing but fining people for recreational marijuana use, 40% favor legalization of small amounts of marijuana, and 80% support legalizing medical use of marijuana. These debates also impact social workers’ sense of social justice, and may in- fluence their role in assessing if a client’s marijuana use is problematic, or just a behavior being unjustly stigmatized as deviant (Raffoul, 2003). If court diversion programs for marijuana offenses expand, will social workers and clients consider mandated referral for marijuana assess- ment and treatment as a legitimate alternative to jail, or another unjust or questionable gambit within a marijuana prohibition policy failure? Either way, it is likely that the expectations for social workers to assess and treat marijuana users may increase (Dennis, Babor, Roebuck, & Donaldson, 2002).
Scientific Debates Add Assessment Dilemmas
Ongoing scientific debates about the harmful or nonharmful as- pects of marijuana add to the marijuana assessment dilemmas. Many clients and clinicians remain uncertain how to sort out the “myths” from the “facts” about marijuana use. Even the President’s National Drug Control Strategy report (2003, pp.13-14) acknowledges this di-
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lemma, indicating that ever since “the 1936 movie Reefer Madness many Americans have been conditioned to think that any warnings about the true dangers of marijuana are overblown.” Although evidence about marijuana’s risks continues to accumulate, many clinicians ap- pear unaware about the current evidence-based findings regarding marijuana. Gambrill (2003, pp. 4, 6) suggests an additional factor com- plicating assessment by pointing out that many “social workers do not draw on practice-related research findings” and remain overreliant upon their own “intuition and unsystematic clinical experiences.”
However, social workers who do review evidence-based marijuana research find that the multiple scientific debates resemble hanging threads of conflicting evidence, more than a coherent tapestry of con- sensus about marijuana’s risks. As Cloud (2002) reports, “the study of marijuana’s health effects is at once more complex and less advanced than you might imagine” (p. 62), adding Earlywine’s (2002) comment that “interpretations of marijuana research may tell more about one’s own biases than the data.”
Five recent books attempt to provide evidence based, scientifically balanced reviews regarding the harmful and nonharmful aspects of mari- juana use (Earlywine, 2002; Gerdes, 2002b; Joy, Watson, & Benson, 1999; Mack & Joy, 2000; Zimmer & Morgan, 1997). While all five re- views overlap in content and effort to clarify the facts from the myths, they often do not arrive at the same conclusions about the evidence. Mar- ijuana and Medicine by Joy et al. (1999) best summarizes the pre-2000 marijuana evidence strengths and limitations, explains why some evi- dence remains inconclusive, and suggests what types of data are neces- sary to support “claims about the harms and benefits attributed to marijuana” (p. 6). However, as the authors state: “Scientific data on controversial subjects are commonly misinterpreted, overinterpreted, and misrepresented, and the medical marijuana debate is no exception” (Joy et al., 1999, p. 1). It is important to note, that despite efforts to avoid such misinterpretation, press coverage of Marijuana and Medicine added to public and professional confusion by giving “the impression the Institute of Medicine fully endorsed smoked marijuana as medi- cine,” when “in fact researchers found little reason to recommend crude (smoked) marijuana as medicine . . . but did conclude the active ingredi- ents could be developed into promising pharmaceuticals” (Mack & Joy, 2000, p. 6). This illustrates how confusion about a scientific conclusion is conveyed.
Controversy about marijuana’s addictive potential, dependency, with- drawal potential, craving, short-term and long-term cognitive ef-
Dale Alexander 13
fects, memory impairment, reproductive health risks, medical benefits, amotivational syndrome, mental health risks, the previously mentioned “gateway theory,” and other areas remain (Gorman & Derzon, 2002; Lynskey & Hall, 2000; Patton et al., 2002; Pope, Grueber, & Hudson, 2001; Smith, 2002). Scientific questions about the innocuous- ness, benefits, or risks of marijuana use remain unresolved. Many au- thorities agree that “heavy” marijuana use can be harmful, but the terms “heavy” or “frequent use” are often not clearly defined as criterion mea- sures across studies (Earlywine, 2002; Zimmer & Morgan, 1997). Inter- pretations also vary about the degree of negative effects associated with “heavy” use. While some consensus exists that marijuana has bio- psychosocial risks, evidence continues to shift back and forth, leaving clinicians and clients uncertain about how to sort out specific myths and facts surrounding marijuana use.
The purpose of this section is not to comprehensively review all con- flicting scientific evidence about marijuana, but only to point out that controversy surrounds many areas of marijuana research. However, it is important to note that, although findings sometimes conflict, there is ample evidence of marijuana’s risk factors, which are summarized later.
CLINICAL ASSESSMENT DILEMMAS WITH MARIJUANA
Clients and clinicians arrive at clinical encounters reflecting the cul- tural and scientific dilemmas surrounding marijuana use. Social work clinicians in nondrug treatment settings are also challenged by addi- tional marijuana assessment dilemmas during clinical encounters. Mar- ijuana is not the client’s presenting problem; clients may be reluctant to disclose marijuana use; clinicians may not know when or how to assess for marijuana problems; marijuana quantity and frequency problem lev- els are not defined; DSM-IV-TR abuse and dependence diagnostic crite- ria for marijuana is problematic; and laboratory screening tests and generic drug inventories are inadequate for marijuana assessment.
Data regarding how often marijuana use is asked about during ini- tial visits or referred to other clinicians are lacking in the literature. Clinical observations indicate that when clients are referred for other psychosocial issues, they are rarely asked about and are hesitant to men- tion marijuana use because they consider their presenting problem “un- related” to marijuana use, worry about the consequences of using an “illegal” substance, concern that they will be automatically “judged” by
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clinicians as “drug addicts,” or that the information may be documented and released to employer health plans. Often, open clinical discussion about marijuana use will occur only after confidentiality issues are ad- dressed.
Clients frequently do not recognize they have a problem with mari- juana, or problems stemming from marijuana use. Clients often de- scribe using “just marijuana” as similar to nonproblematic alcohol use and do not consider it a drug with the potential to become a problem. Prochaska (2000) proposes a “40, 40, 20 rule” to describe the general dilemma of client readiness to recognize or change health risk behav- iors, and the potential mismatches this creates with clinician expecta- tions. When applying this “rule” to marijuana users, it can be assumed that 40% of clients arrive in a “precontemplation” stage, not aware mar- ijuana use is a “problem” and not considering any need to change. An- other 40% arrive in the “contemplation” stage with some awareness of the pros and cons of marijuana use, but not prepared to take action. At best, 20% of clients may arrive in a stage of “preparation,” aware they have a marijuana problem and ready to consider taking action soon (Prochaska, 2000).
Client reluctance to discuss marijuana is compounded when clini- cians do not know when, how, or what to assess, nor how to recognize problematic marijuana use. Since there is a general lack of recognition of alcohol problems among clinicians in nonsubstance abuse settings, there is no reason to believe that there will be any higher recognition rate for marijuana problems (Aalto et al., 2002; Dennis et al., 2002; Googins, 1984; Haack & Adger, 2002). It is common to find social work students and even professional social workers either not asking or not framing questions properly when confronted with a client with a po- tential substance use problem. It is important to avoid terminology like “abused” or “illicit ”drugs and more helpful to reframe questions about “recreational drug use,” clarifying this includes marijuana. Social work clinician failure to ask about or adequately explore marijuana use could play an “enabler” role and add to the assessment dilemmas (Levinson & Straussner, 1978).
Marijuana Quantity, Frequency and Continuum of Use Assessment Dilemmas
The National Institute of Alcohol Abuse and Alcoholism (1995) established quantity and frequency guidelines for a “standard drink” and “at risk” or “abuse” level drinking for men, women, and seniors.
Dale Alexander 15
However, there are no similar scientifically established quantity and frequency risk guidelines for marijuana. This presents a clinical as- sessment dilemma in determining who, among all those using mari- juana, does so at a quantity and frequency sufficient to establish “at risk” use of marijuana (Kandel & Chen, 2000; Swift, Copeland, & Hall, 1998). Marijuana quantity and frequency assessment is also complicated by dose level variations in the psychoactive ingredient, delta-9-tetrahydroncannabinol, known as THC. Since 1974 the average THC content has increased from 1% to 7% or higher in 2000 (Bush, 2003; Thorton, 1998). Clinicians gauging marijuana quantity and fre- quency may not account for higher present day THC levels.
There is no consensus in marijuana assessment about terms describ- ing a continuum of use, such as “experimental,” “regular,” “frequent,” “heavy,” or “long-term user.” Differentiations between these terms are blurred and inconsistently defined in marijuana research studies. For example, Joy and Mack (1999, p. 48) state that most who “try” mari- juana “are not regular users,” without behaviorally defining “regular user.” Shedler and Block (1990) describe “experimenters” as using only marijuana at frequencies varying from “once a month,” to “once or twice,” to “a few times,” which suggests a range beyond the initial “once a month” definition. These authors describe a marijuana “fre- quent user” as one who combines marijuana with another illicit drug which converts the definition into poly-drug use, and a frequency crite- ria of “once a week or more,” opening the range from four to 30 times a month. This “frequent user” definition does not match the National Household or Monitoring the Future highest frequency ranges of 300 days a year, or 20 times a month for marijuana only use.
Complicating marijuana assessment further is the fact that correla- tions between marijuana quantity and frequency levels with negative outcomes have not been empirically established. For example, some studies find that “experimenters” are psychologically healthier than “abstainers,” and “heavy users . . . indistinguishable” from “occasional marijuana smokers” on mental health measures (Kouri et al., 1995; Shedler & Block, 1990).
DSM-IV-TR Diagnostic Dilemmas Regarding Marijuana Assessment
The DSM-IV-TR (2000) remains the most influential diagnostic sys- tem for substance use disorders, although criticism exists about its va- lidity and reliability (Kutchins & Kirk, 1997). The DSM-IV-TR (APA,
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2000, p. 235) states, “There are no unique criteria sets for cannabis de- pendence or cannabis abuse.” However, the use of “generic” DSM- IV-TR criterion for dependence and abuse presents diagnostic dilemmas for marijuana assessment. Distinctions regarding whether three of the seven criteria meet the standard for dependence or one of four criteria meet the “maladaptive pattern” for abuse raise questions of how well they “fit” when applied to marijuana (APA, 2000, pp. 197, 199). Lack of clarity and consensus on these criteria decrease diagnostic reliability among different clinicians diagnosing cannabis “dependence” or “abuse” (Schuckit et al., 1999; Swift et al., 1998; Winters et al., 1999).
Marijuana “addiction” or “dependence” is difficult to assess for sev- eral reasons. Reviewing the lack of “fit” with marijuana for the three major criteria for dependence illustrates this cannabis diagnostic di- lemma. The concepts of tolerance, withdrawal and craving (which en- compasses difficulty cutting down and taking “larger amounts” over a longer time than intended) are the major criteria for dependence. De- pendence correlates with higher dose levels over time due to the devel- opment of “tolerance.” But complicating marijuana dose-dependence tolerance assessment are the facts that many marijuana smokers do not use every day, dose level and potency vary, and marijuana quantity and frequency criteria are not established, confusing the definition of “larger amounts.” While Joy and colleagues (1999) conclude that “tol- erance” to marijuana’s affects exists and can develop rapidly after only a few doses, they also indicate that tolerance disappears rapidly, poten- tially making tolerance clinically nonsignificant. Mirroring the unre- solved debate on cannabis withdrawal, the DSM-IV defines withdrawal criteria for alcohol, cocaine, amphetamines, nicotine, opioids, seda- tive-hypnotics, and anxiolytics, but states “cannabis withdrawal is not included in this manual” (DSM-IV-TR, 2000, p. 235). Joy et al. (1999, p. 57) state “a distinctive marijuana THC withdrawal syndrome has been identified, but it is mild and subtle compared with the profound physical syndrome of alcohol or heroin withdrawal.” Subsequent re- search by Budney (1999) reports a clinically significant cluster of mari- juana withdrawal symptoms in a majority of adults ceasing “regular . . . daily” use, while Smith’s (2002) review continues to cast doubt upon the existence or clinical significance of marijuana withdrawal in hu- mans. Drug “craving” is another established component of dependence for nicotine, alcohol, cocaine, and opiates, but “craving” for marijuana has not been clearly established, leaving the validity of this concept also unresolved (Heishman, Singleton, & Liguori, 2001; Joy et al., 1999).
Dale Alexander 17
Assessment of marijuana dependence is also confounded when other drugs or co-existing mental disorders are involved. Evidence exists that polysubstance users with other psychiatric disorders may have higher vulnerability to developing marijuana dependence (Joy et al., 1999). The best summation of the “dependence” evidence to date is that many questions remain whether DSM-IV-TR cannabis “dependence” criteria are fully met or clinically significant; whether “dependence” is physical or only psychological; and whether tolerance, withdrawal, or craving exist as valid phenomena supporting physical dependence on marijuana (Budney, Novy, & Hughes, 1999; Kouri, Pope, & Lukas, 1999; Smith, 2002).
There are also questions of how well DSM-IV-TR generic “abuse” criteria applies to marijuana use. Some clinicians automatically con- sider “any use” of marijuana, or use within “the last six months” as be- ing “at risk” for substance abuse (Fleming, 2002, p. 51). But given the widespread, intermittent use of marijuana, such an automatic diagnosis based upon “any use” or “within six months” appears rigid and risks be- ing clinically inaccurate. While “any use” of marijuana is illegal and may occur in a “physically hazardous” situation, risking adverse conse- quences for “legal problems,” and then disrupt “major role obliga- tions,” such use may still not meet the “recurrent” use criteria. A DSM-IV-TR diagnosis of substance abuse specifies “recurrent” mari- juana use in all four criteria, one of which may meet the “maladaptive pattern” necessary for “clinically significant impairment or distress” (DSM-IV 2000, p. 199). But subjective clinical judgment enters into “Cannabis Abuse” criterion distinctions about the meaning of “recur- rent use,” “maladaptive pattern,” or “clinically significant impairment.” While recurrent use may be suggested by five to 10 times a month, is this low or high? No empirically established “at risk” marijuana quan- tity and frequency guidelines exist. Likewise, are behavioral or fre- quency cutoff guidelines sufficiently clear regarding how many “legal,” “driving,” “role obligations,” or “interpersonal problems” with mari- juana are necessary to reach clinical agreement that a “recurrent,” “maladaptive pattern” exists? Connecting marijuana use to “failure” in fulfilling “major role obligations” or “causing or exacerbating . . . social or interpersonal problems” also calls upon clinical judgments that are often subjective and may require more extensive assessment time and training in substance abuse and DSM-IV than many social work in nonsubstance abuse setting possess (Dziegielewski et al., 2002; Straussner & Senreich, 2002).
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Even NORML, the National Organization for Reformation of Mari- juana Laws, agrees that “marijuana can be harmful when abused,” ad- vocating “responsible marijuana use,” restricted to “adults only,” and “no driving” during use (Stroup, 1999, p. 9). NORML reports diffi- culty in defining what constitutes abuse, adding that if “marijuana abuse is to be targeted, it is essential that clear standards be developed to identify it” (Stroup, 1999, p. 12). While substance abuse specialists may hesitate to agree with a NORML position, it may be constructive to acknowledge that diagnostic dilemmas around marijuana abuse exist. Developing clear behavioral criterion cut offs for what constitutes a marijuana abuse or dependence pattern merits more research attention.
The DSM-IV-TR (2000) estimates the lifetime rates of Cannabis Abuse or Dependence at five percent. Regardless of the controversies and marijuana assessment dilemmas discussed, Cannabis Use Disor- ders are recognized and clinical experience confirms marijuana use may reach criterion levels for classification as Cannabis Abuse or Cannabis Dependence, With or Without Physiological Dependence (DSM-IV-TR, p. 236). Cannabis Disorders merit better assessment and screening tools to aid in proper diagnosis.
Inadequacy of Existing Lab Tests and General Drug Screening Inventories
Biochemical lab tests and existing standardized drug screening in- ventories may be helpful assessment aids, but have limitations compro- mising their effectiveness in assessing marijuana use patterns. Existing marijuana screening efforts consist primarily of biochemical laboratory tests, which include four urine screens, a sweat, and a saliva test (James & Moore, 1999; Mura et al.,1999). While biochemical laboratory tests are generally accurate, they only determine past marijuana use, and one dose of THC requires 12 to 30 days to leave the body (Earlywine, 2002; Riley, Lu, & Taylor, 2000). However, the clinical assessment task is not just to establish past use, but assess if present marijuana use constitutes a high- or low- risk problem pattern. Most clinicians in outpatient men- tal health or social service settings interested in assessing marijuana use do not have access to sophisticated laboratory facilities and tests, nor the knowledge necessary to interpret lab values. Clients presenting vol- untarily may not agree to a lab referral, or the extra costs and require- ments for providing urine or blood (Fendrich & Kim, 2002).
Client cooperation with marijuana assessment may be improved by asking clients to complete a brief self-report questionnaire. However,
Dale Alexander 19
existing paper and pencil screening inventories are limited because they ask only about “drugs” in general and are not designed to specifically assess marijuana use (Brown et al., 1997; Knight, 1999; Maisto et al., 1999). Longer screening inventories may only mention marijuana among other drugs, or at best have one or two embedded items regarding mari- juana (Miller, 1999; NIDA, 1993; Winters, 1999). Although three re- cent marijuana specific questionnaires were located, they were not designed for screening clients to determine problematic or nonproblem- atic marijuana use. The “Marijuana Effect Expectancy Questionnaire” (MEEQ) was developed to assess the “expectancy” of effects associ- ated with drugs (Aarons et al., 2001). The “Marijuana Craving Ques- tionnaire” (MCQ) was developed to access the “craving” concept related to dependence or relapse (Heishman et al., 2001), and the “Mari- juana Quit Questionnaire” (MQQ) was designed to access difficulties in quitting (Gorelick et al., 2002).
TIME FOR MARIJUANA SPECIFIC SCREENING METHODS?
Although scientific controversy still surrounds the harmfulness or harmlessness of marijuana use, past and present literature continues to report numerous physical, psychosocial and behavioral problems asso- ciated with “heavy” or “frequent” marijuana use in adolescents and adults. Evidence of marijuana’s risks are well summarized in Joy’s et al. (1999) review in Marijuana and Medicine and augmented by more re- cent research (Earlywine, 2002; Galif et al., 2001; Green & Ritter, 2000; Gorman & Derzon, 2002; Kouri et al., 1999; Kurzthaler et al., 1999; Ramaekers et al., 2000; Solowij et al., 2002; Zickler, 2000). Even with problems in assessing and recognizing marijuana abuse in general mental health and primary care settings, marijuana abuse admissions to specialty drug and alcohol treatment facilities are increasing beyond the 14% level reported in 2002 (SAMHSA DASIS, 2002). Between 1993 and 1999 marijuana treatment admission rates increased in 41 out of 50 states; by as much as 100% in 18 states (SAMHSA DASIS, 2002). While this increase may be due to people choosing treatment over crim- inal sanctions, it may also suggest that more people are experiencing adverse psychobiosocial consequences to marijuana. Such increases in admissions indicate that clinicians in substance abuse settings are seeing more clients with marijuana abuse problems. Concurrently, ex- pectations may increase for social work generalist to develop more competence in recognizing and assessing marijuana problems earlier.
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Cannabis abuse recognition and treatment are areas of “historic ne- glect” in the addiction treatment literature. There is a need to provide greater emphasis on recognizing and treating cannabis use disorders (Dennis, Babor, Roebuck, & Donaldson, 2002). Recognition and detec- tion of problematic marijuana use can be improved if clinicians proactively initiate assessment specifically for marijuana use. Social workers need to ask directly about marijuana use, even when clients are referred for depression, anxiety or couple’s issues. Fleming (2002, p. 50) cites data suggesting “clinicians will be able to detect more than 80% of drug users if they limit their initial screening questions to mari- juana.”
Clearly, there is need for a marijuana specific screening inventory. Marijuana’s prevalence suggests it merits the same specific assessment attention as alcohol risks. While numerous alcohol specific screening inventories exist for assessing the 48% to 58% of past year alcohol drinkers, similar marijuana specific screening inventories have not been developed to assess the estimated 9.3% to 26.7% of past year marijuana users (Babor et al., 1992; Blow et al., 1992; Brown et al., 1997; NIAAA, 2001; Russel, 1994; Reinart & Allen, 2002; SAMSHA, 2002b). Mari- juana screening will require development of appropriate screening in- ventories that are reliable, valid, accepted, and utilized widely enough to improve recognition of marijuana problems in proportion to their prevalence. Such marijuana specific screening inventories are currently in the early stages of development (Alexander, 2003).
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RECEIVED: 09/20/02 REVISED: 04/17/03
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